Provider Demographics
NPI:1205978996
Name:BINGAMITE
Entity type:Organization
Organization Name:BINGAMITE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:KORSCH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:218-722-3977
Mailing Address - Street 1:113 N 2ND AVE W
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1911
Mailing Address - Country:US
Mailing Address - Phone:218-722-3977
Mailing Address - Fax:218-726-9087
Practice Address - Street 1:113 N 2ND AVE W
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1911
Practice Address - Country:US
Practice Address - Phone:218-722-3977
Practice Address - Fax:218-726-9087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN200610-93336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN24-22638OtherNABP
MN1255370001Medicare NSC